It is with a great sense of honor and pleasure that we present this year's
update for the subspecialty of sports medicine. Our field was once again the
most popular fellowship choice among graduating orthopaedic residents this
past year. While many of us are wrestling with exactly what our ever-expanding
field includes, especially while we prepare for the upcoming specialty
certification that looms near, we can all agree that our primary concern
should be the treatment of athletes. Whether these athletes come from the
playground, the sandlot, or the stadium, we share this one common thread.
This update is based on scientific and organizational activities in sports
medicine that took place from September 2004 to August 2005. It includes a
summary of the Annual and Specialty Day meetings of the American Orthopaedic
Society for Sports Medicine (AOSSM), the Arthroscopy Association of North
America (AANA), and the American Academy of Orthopaedic Surgeons (AAOS). These
meetings featured over 200 scientific presentations focusing on sports
medicine. In addition, the three most influential journals in our
field—specifically, The Journal of Bone and Joint Surgery (American
Volume), The American Journal of Sports Medicine, and
Arthroscopy—will be reviewed.
Appropriate management of the posterolateral corner of the knee is integral
to the successful treatment of a multiple-ligament knee injury. Recognition of
these injuries, especially on the basis of physical examination findings (for
example, external rotation asymmetry as demonstrated with use of the dial
test) and magnetic resonance imaging findings, is improving. Reconstruction of
injured lateral-side structures is generally recommended over primary repair
alone; however, primary repair with augmentation is still the best option for
acute injuries (i.e., those treated within the first two weeks). Postoperative
early range-of-motion protocols are important for successful outcomes.
Biomechanical studies have shown that the loads across the lateral collateral
ligament are higher in extension and that the popliteus and popliteofibular
ligaments are subjected to higher loads with higher degrees of
Anatomically based repairs are more sound, both biomechanically and
Posterior Cruciate Ligament
The posterior drawer test remains the gold standard for the diagnosis of
posterior cruciate ligament injuries. Many authors have suggested that stress
radiographs provide the best objective translation data for posterior cruciate
ligament-injured and reconstructed knees. Additionally, the value of
double-bundle reconstructions continues to be debated. Currently, there is no
consensus in the literature regarding single as opposed to double-bundle
Lower-grade posterior cruciate ligament injuries are still best treated
nonoperatively. A recent study demonstrated that, despite objective laxity,
patients with grade-I or II posterior cruciate ligament injuries were able to
perform gait and drop-landing activities similar to uninjured
Additionally, subjective results in patients with posterior cruciate ligament
deficiency were not correlated with objective laxity measurements. However, a
recent cadaveric study demonstrated that stress increased in both the medial
and the lateral meniscus with complete disruption of the posterior cruciate
ligament and normalized after reconstruction of the posterior cruciate
If the posterior cruciate ligament does need to be reconstructed, the
status of the posterolateral corner must be properly evaluated and treated.
Failure to address the posterolateral corner has been shown to cause the
failure of posterior cruciate ligament (and anterior cruciate ligament)
reconstructions. Magnetic resonance imaging studies have shown that the
prevalence of bone-bruising in patients with posterior cruciate ligament
injuries is as high as that in patients with anterior cruciate ligament
injuries but that the bruising pattern is more variable in the former group.
The presence of the bruising should alert the surgeon to other potential
injury sites. Sekiya and colleagues evaluated the biomechanical effect of
reconstructing both the posterior cruciate ligament and the posterolateral
corner in patients with combined
reconstructions nearly restored native knee kinematics and demonstrated
load-sharing among the grafts, creating a potentially protective effect
against early posterior cruciate ligament failure, with increased force
transmitted to the posterolateral corner reconstruction. Other causes of
failure of posterior cruciate ligament reconstructions include incorrect
tunnel placement and the failure to address varus malalignment. Lower
graft/femoral tunnel angles can be obtained with the outside-in as compared
with the inside-out technique of establishing femoral
tunnels6. Kim et
al., in a biomechanical study, demonstrated that central and lateral tibial
tunnels exhibited lower stress between the ligament and the so-called killer
Anterior Cruciate Ligament
Anterior cruciate ligament injuries continue to be common, and substantial
strides continue to be made in both the prevention and treatment of these
injuries. Many reports in the sports medicine literature have demonstrated
that neuromuscular training has a beneficial effect on reducing the prevalence
of anterior cruciate ligament injuries. Videotape evaluation and feedback also
has been shown to improve the mechanics of jumping and landing, possibly
decreasing the prevalence of jump-landing anterior cruciate ligament
Additionally, sport-specific interventions are being implemented in the
training of athletes to help to decrease the prevalence of anterior cruciate
ligament injuries. Specifically, athletes who carry a ball or stick are at
increased risk for anterior cruciate ligament injury when their plant-side arm
is constrained at the side. Risk factors associated with landing anterior
cruciate ligament injuries generally include narrow base (landing with feet
close together), valgus alignment, and landing with the knee in extension.
A prospective evaluation of risk factors in female athletes documented a
2.5-times higher knee abduction moment at landing and a 20% higher
ground-reaction force with decreased stance time in athletes who had sustained
an anterior cruciate ligament
injury9. Despite the
discrepancy in the rates of anterior cruciate ligament injury between male and
female athletes, the overall prevalence of anterior cruciate ligament injuries
remains low and there are no recommendations to limit sports activity among
female athletes in any
Additional factors associated with anterior cruciate ligament injuries
include a positive family history of anterior cruciate ligament injury (with
patients who have a positive history being two times more likely to sustain an
anterior cruciate ligament injury), muscular fatigue associated with increased
anterior tibial shear force, and increased valgus and decreased knee flexion
angles at landing. The role of estrogen and estradiol concentration continues
to be studied. Some studies have demonstrated a relationship between the
prevalence of anterior cruciate ligament tears and cyclic estrogen surges, and
other studies have refuted this temporal relationship. The effect of estrogen
on anterior cruciate ligament fibroblasts was evaluated in an animal model
that demonstrated the presence of estrogen receptors in ovine anterior
cruciate ligament fibroblasts; however, there was no significant difference in
anterior cruciate ligament fibroblast proliferation or collagen synthesis,
regardless of the concentration of
On the basis of the results of that study, and given the low turnover of
collagen in ligaments, it is thought to be unlikely that a two to
three-day-per-month increase in circulating estrogen would result in
clinically important alterations in the material properties of the anterior
cruciate ligament in vivo. Finally, the importance of the femoral notch and
its relationship to anterior cruciate ligament injuries has been questioned. A
prospective study followed 305 National Basketball Association (NBA) players
over eleven years after evaluation of the notch size and notch-width
index12. These data
were compared with those from the NBA's league-wide injury database, and the
notch size and notch-width index were not found to be predictive of anterior
cruciate ligament injury in these athletes.
The choice of graft material for anterior cruciate ligament reconstruction
continues to be a source of debate. Excellent results have been reported in
association with bone-patellar tendon-bone autograft, hamstring autograft,
quadriceps autograft, and allograft. When allograft is used, it is extremely
important to be familiar with the rules and screening procedures of the tissue
bank from which the graft is obtained. Early failure of anterior cruciate
ligament reconstructions continues to be related to graft fixation, and many
fixation devices are available. Regardless of the method chosen, it is
imperative that stable initial graft fixation be achieved. Supplementary
staple fixation in the tibia has been associated with improved laxity
measurements and clinical stability two years after reconstruction of the
anterior cruciate ligament with a hamstring graft. However, this improvement
comes at the cost of increased pain during kneeling. The stability of the
reconstructed anterior cruciate ligament depends on many factors, including
fixation strength, tunnel placement, and graft tension. The exact tension that
is required for stability of an anterior cruciate ligament graft remains
unknown; however, studies have indicated that an initial graft tension of
>45 N is required to restore objective laxity measurements.
Many authors are currently investigating the need for a double-bundle
anterior cruciate ligament reconstruction. The idea that a double-bundle
reconstruction may more accurately restore knee kinematics in flexion as well
as extension has stimulated much interest in the indications for, feasibility
of, and results of this type of
To date, there is no clear indication that the use of a double-bundle
technique will improve the clinical results of anterior cruciate ligament
Attempts to encourage faster tendon-to-bone healing following anterior
cruciate ligament reconstruction continue to be made. The addition of bone
morphogenetic protein-7 (BMP-7) to the bone tunnels at the time of
reconstruction with use of a patellar tendon graft was associated with earlier
and better bone-healing and better biomechanical properties of the
reconstructed anterior cruciate ligament. These findings suggest that BMP-7
augmentation is beneficial for anterior cruciate ligament reconstruction,
especially for athletes who are seeking an earlier return to play. A rabbit
study demonstrated that coating hamstring tendon grafts with mesenchymal stem
cells resulted in a tendon-bone interface that more closely resembled the
natural tendon-bone interface as well as in a higher failure load and
stiffness at eight weeks. Another animal study demonstrated that the addition
of a bone dowel in the tibial tunnel with standard soft-tissue graft fixation
increased initial fixation stiffness and increased fit, which is known to
enhance tendon graft-to-bone healing.
The appropriate treatment of partial thickness injuries and stretch
injuries of the anterior cruciate ligament also remains unclear. Arthroscopic
thermal shrinkage for the treatment of anterior cruciate ligament laxity and
partial thickness tears has been associated with long-term catastrophic
failure and is no longer recommended. One study showed that the addition of
exogenous growth factors had a beneficial effect on the healing of stretch
injuries of the anterior cruciate ligament.
There is a trend toward early reconstruction of the anterior cruciate
ligament-deficient knee, especially in younger, more active patients. Many
reports in the literature have documented favorable results in association
with this approach. Early reconstruction has been shown to result in less late
meniscal surgery and reduced knee laxity and symptomatic instability. However,
reconstruction does not appear to reduce the risk of late radiographic
degenerative changes. Another study demonstrated that reconstruction of the
anterior cruciate ligament was associated with a decreased rate of reoperation
(p < 00001) and that younger age was a strong predictor of failure of
nonoperative treatment of anterior cruciate ligament
thirty-five-year follow-up study of elite East German athletes documented the
ability to return to sports after nonoperative treatment of an anterior
cruciate ligament injury; however, 95% of the athletes had meniscal and
cartilage damage over the next twenty years, and many were at high risk for
needing a joint
The anterior cruciate ligament is frequently involved in multiple-ligament
knee injuries, and the most common injury combination involves the anterior
cruciate and medial collateral ligaments. Early repair of ligament injuries is
associated with a lower risk of articular and medial meniscal tears than late
repair is. The risk of meniscal injuries increases when anterior cruciate
ligament reconstruction is performed more than six months after the injury,
and chondral damage is more common if reconstruction is performed more than
one year after the
The postoperative treatment of anterior cruciate ligament reconstructions
is of paramount importance for obtaining and maintaining good functional
outcomes. Early accelerated and early nonaccelerated rehabilitation protocols
have been associated with similar increases in anterior cruciate ligament
laxity two years postoperatively, and both protocols have produced similar
outcomes in terms of clinical results, patient satisfaction, function, and
biomarkers of cartilage metabolism. Postoperative functional bracing has not
proven to be beneficial after anterior cruciate ligament reconstruction.
Continued concerns about weakness in flexion and internal rotation after
reconstruction of the anterior cruciate ligament with a hamstring autograft
has led some authors to question the need to include the gracilis when
harvesting the hamstring tendons. Despite the findings of magnetic resonance
imaging studies and animal studies that have documented regeneration of the
hamstrings, weakness in high degrees of flexion persists. A posterior
mini-incision technique for harvesting hamstring grafts has been shown to be
easy, to provide excellent cosmesis, and to have no problems with cutting
grafts short. A two to eight-year follow-up study showed reliable and durable
stability and good clinical ratings in association with the use of this
A new test designed to help to diagnose meniscal abnormalities has been
described. This test, known as the Ege test, is performed with the patient
bearing weight. The Ege test is equivalent to the McMurray test and joint-line
tenderness in demonstrating meniscal tears. Inclusion of the Ege test during
clinical examination may improve the accuracy of evaluation of the
The gold standard for meniscal repair remains the inside-out vertical
mattress suture. Attempts at all-inside repairs have been made with meniscal
arrows, and the results generally have been unfavorable. Six-year follow-up
demonstrated inferior results compared with inside-out
Additionally, chondral damage has been reported after the placement of these
arrows, with progression seen even after removal of the
Improved results have been reported in association with other all-inside
techniques, specifically, the FasT-Fix. This device has shown higher pullout
strength than conventional vertical mattress sutures under cyclic loading and
load-to-failure testing. The two-year results of FasT-Fix repairs in the
red-red or red-white zone are comparable with those of classic suture-repair
The treatment of meniscal cysts remains controversial. These lesions are
most commonly found laterally, and excellent results are obtainable with
partial meniscectomy and cyst débridement. Recurrence appears to be
related to overly conservative meniscectomy.
The science and technology of meniscal transplantation continues to evolve.
The indications for this procedure are gradually becoming clearer. On the
basis of animal data, it appears that immediate transplantation following
meniscectomy has a protective effect on articular cartilage, whereas delayed
meniscal transplantation is associated with more severe articular cartilage
changes than are seen without any transplant. If applicable to humans, this
suggests that immediate meniscal transplantation may be beneficial in cases of
meniscal damage necessitating a complete or near complete
The five-year results associated with collagen meniscal implants were
reported for eight patients. The meniscus-like tissue maintained its structure
and functioned without any negative effects. The patients had improvement
after the procedure and demonstrated no additional degenerative changes;
however, the long-term chondroprotective effects remain unknown.
A study of asymptomatic NBA players who were evaluated with magnetic
resonance imaging demonstrated that 47% had articular cartilage lesions and
20% had meniscal lesions, reinforcing the premise that magnetic resonance
imaging abnormalities alone are not adequate, in the absence of clinical
findings, to define pathological
Cartilage lesions remain troubling for both the physician and the patient.
There are numerous options for treatment, depending on the nature of the
lesion itself. Osteochondral autograft transplantation is an excellent option
for the treatment of cartilage defects, particularly those in younger
individuals with a short duration of symptoms. Animal data have shown that a
minimally countersunk autograft can remodel and correct small incongruities;
however, deeper seated grafts are unable to do so. If the lesion is unstable,
it can be secured back to bone with use of bioabsorbable screws with good
results21. If the
lesions are not amenable to chondral repair or transplantation, then
microfracture is the next best option. Protected weight-bearing allowed for
complete filling of the defect with more mature cartilage and bone repair in a
Despite the fact that many patients have had dramatic (although not
permanent) improvement, the treatment of osteoarthritis with knee arthroscopy
recently has fallen out of favor. Despite negative reports, recent literature
has shown that the presence of cartilage debris increases the expression of
tumor necrosis factor-alpha (TNF-a) and that arthroscopic lavage may
reduce symptoms in osteoarthritic knees by removing cartilage debris and
decreasing the expression of
Piroxicam was found to improve medial collateral ligament healing in a rat
model. This finding does not apply to other nonsteroidal anti-inflammatory
drugs, cyclooxygenase-2 (COX-2) inhibitors, or opiate analgesics. Preoperative
administration of COX-2 inhibitors has reduced postoperative pain and narcotic
use after knee arthroscopy, but the use of these agents is extremely
controversial at this time because of potential harmful side effects. There
are also concerns regarding the effects of nonsteroidal anti-inflammatory
drugs and COX-2 inhibitors on bone-healing. Herbenick reported a decrease in
the quality of callus formation during fracture-healing following the
administration of a COX-2 inhibitor. Detrimental effects on early tendon
repair also have been seen in association with COX-2 inhibitors; however,
during tendon remodeling, inflammation appears to have a negative influence,
and cyclooxygenase-2 inhibitors might be of
Anterior knee pain and patellofemoral problems are commonly seen in the
outpatient setting. These problems are often chronic and difficult to treat.
Recurrent patellar instability can be addressed with soft-tissue procedures,
osseous procedures, or a combination of both. Excellent long-term stability
has been seen following the Roux-Elmslie-Trillat procedure for the treatment
of dislocation or subluxation of the
the long-term functional status of these patients continues to decline.
A four-year follow-up study of twenty-two patients who were managed with a
mini-open medial reefing and arthroscopic lateral retinacular release for the
treatment of recurrent patellar dislocations showed excellent patient
satisfaction, with one case of instability and one case of subluxation. These
results compare favorably, in terms of cosmesis and outcome, with those of
more traditional and extensile surgical approaches to this difficult problem.
Lateral release should be reserved for patients with objective evidence of
patellar tilt. Acute patellar dislocations commonly involve an injury of the
medial patellofemoral ligament. Multiple methods of reconstruction of the
medial patellofemoral ligament have been described, all with good results, and
medial patellofemoral ligament reconstruction alone has been shown to be as
successful as distal realignment procedures. Regardless of the technique
chosen to restore patellofemoral stability, it is clear that a lateral release
alone is insufficient for the treatment of patellar instability.
Treatment of patellar tendonitis remains difficult and is often unrewarding
for the patient. The role of thermal microdébridement continues to
evolve as a treatment for many chronic tendinopathies. A cadaveric study
evaluating the effect of thermal microdébridement on the biomechanical
properties of the patellar tendon demonstrated no significant difference
between specimens treated with thermal microdébridement and controls
with regard to ultimate stress at failure, elastic modulus, strain energy
density, or strain at maximum load. Additional studies involving the use of an
in vivo model will be required to completely assess the effects of thermal
microdébridement on the biomechanical properties of human patellar
The diagnosis and operative treatment of "symptomatic" plica is
perhaps too common. A case series described three symptomatic
"bucket-handle tears" of the medial patellar plica in professional
soccer players. All of these athletes had symptomatic relief following
arthroscopic excision. The etiology of the symptomatic plica remains
The vascular anatomy of the acetabular labrum has been better defined.
While there is an overall poor vascular supply to the labrum, the best and
most consistent supply was found on the capsular side at the attachment to the
Hip arthroscopy is becoming a more commonly used procedure to identify and
treat conditions of the acetabular labrum. Arthroscopic débridement of
acetabular labral tears has been associated with good results when patients
with disability claims are excluded. A good correlation between improvement in
the SF-36 and modified Harris hip scores after arthroscopic partial limbectomy
has been established. Arthroscopic partial limbectomy was performed in one
series of ten hips with early osteoarthritis and acetabular hypoplasia, with
no evidence of progression of the osteoarthritis and good relief of pain.
Acetabular labral tears with underlying chondral injury were found in a subset
of high-level runners, suggesting an injury pattern common in this
Femoroacetabular impingement is a relatively new diagnosis in patients with
mechanical hip pain. Resection osteoplasty of the proximal part of the femur
has been effective for reducing pain and may be performed either openly or
arthroscopically. Regardless of surgical technique, the resection should not
encompass >30% of the anterolateral quadrant of the head-neck junction of
the femur because of the risk of fracture with larger
Snowboarder's ankle, a fracture of the lateral process of the talus, is
commonly thought to be an ankle sprain and therefore is commonly missed.
Patients are often referred to orthopaedists for the treatment of lingering
problems associated with the "ankle sprain." Injuries tend to
involve the board-leading leg and are more frequent in novice boarders. Elite
boarders tend to sustain back and knee injuries more commonly than ankle and
wrist injuries. Large fracture fragments of the lateral process should be
fixed so that early weight-bearing can begin in a fracture
Decreased peroneus longus muscle activity is associated with lateral ankle
instability and recurrent ankle sprains. For patients requiring stabilization,
the Brostrom lateral ankle reconstruction continues to be the standard
treatment for recurrent lateral ankle instability. Multiple new techniques
have been described to reconstruct the lateral side of the ankle with use of
gracilis autograft and fixation with interference screws. Recently,
arthroscopic thermal shrinkage was used for the treatment of refractory
lateral ankle instability in twenty-two young, male soccer players, with
eighteen of the twenty-two patients showing no evidence of ankle instability
at forty-two months and twenty-one of the twenty-two patients returning to
sports activity at the same level. The presence of focal chondral lesions of
the ankle joint does not negatively affect the results of lateral ligament
reconstruction when preoperative weight-bearing radiographs of the ankle do
not show any joint-space narrowing. Autogenous osteochondral grafts in the
talar dome have shown good results that have been predictably better in
patients with smaller lesions.
Ultrasound has proved to be effective for the evaluation of peroneal tendon
tears. The advantages of ultrasound as compared with other imaging techniques
are that it can be done in the office, it is quicker and less expensive, and
it can be performed dynamically. The utility of ultrasound for the evaluation
of the foot and ankle region as well as throughout the rest of the body
remains dependent on the operator's ability and the physician's familiarity
with reading and interpreting the results.
Operative fixation of Jones fractures continues to be the treatment of
choice for athletes. Numerous studies have confirmed that operative treatment
with intramedullary fixation allows for a shorter time to union and a quicker
return to desired activity. The minimum size of screw that is needed appears
to be 4.0 mm. Return to sports activity is commonly possible at seven or eight
weeks. Screws measuring <4 mm are discouraged because of increased failure
rates. Numerous investigators have advocated operative treatment of Jones
fractures in nonathletes as
Stress fractures in the foot continue to plague the endurance athlete, and
muscle fatigue has been correlated with increased maximal force, peak
pressure, and impulse under the second and third metatarsal heads and under
the medial aspect of the midfoot toward the end of a fatiguing run. The
demonstrated alteration of the rollover process with increased forefoot
loading may help to explain the prevalence of stress fractures of the
metatarsals under fatiguing loading conditions.
Plantar fasciitis remains a difficult problem that is still best treated
nonoperatively. Refractory cases treated with extracorporeal shock wave
therapy continue to show good results.
Repair of the ruptured Achilles tendon remains associated with a lower
rerupture rate; however, repairs in patients who are less than thirty years of
age have been associated with an increased rate of rerupture as compared with
those in older patients. The use of caution in the postoperative
rehabilitation regimen of these younger patients may decrease this rate.
The treatment of athletes who have pars defects remains nonoperative,
although there have been reports of successful treatment of spondylolysis with
posterior stabilization. Athletes with unilateral spondylolysis have increased
stress at the contralateral pars and are susceptible to the development of
contralateral pars fractures.
The Brostrom lateral-side reconstruction remains the gold standard, and a
technique to perform lateral ankle ligament repair safely in the skeletally
immature patient with use of suture anchors has been described.
Good results have been reported in association with percutaneous drilling
of the symptomatic accessory navicular in young athletes, with excellent
patient satisfaction and an 80% rate of bone-healing in patients with open
The on-field treatment of cervical spine injuries in football players still
includes leaving the helmet and shoulder pads on. Facemask removal is the
standard of care. The physician and trainer covering events need to be
familiar with the various types of helmets and straps that may be encountered.
Football helmets and facemasks were tested by having certified athletic
trainers remove the equipment under various
Shockblocker loop strap was consistently superior in all variables tested,
regardless of the tool used or the helmet to which it was attached. The
cordless screwdriver created less movement, was faster, and was less difficult
to use compared with cutting tools. Trial failure was more common with cutting
tools than with the screwdriver. However, familiarity and competence with the
cutting tools for facemask removal are necessary because facemasks often are
not easily removed with a screwdriver because of age, rust, or infrequent or
De Quervain stenosing tenosynovitis has been commonly found in professional
volleyball players and is likely related to training time and consequent
microtrauma. First-line treatment remains nonoperative, with activity
restriction, nonsteroidal anti-inflammatory drugs, or steroid injections. No
benefit has been noted in association with the combination of nonsteroidal
anti-inflammatory drugs and a steroid injection in the first dorsal
Professional catchers have more subjective hand symptoms, particularly
weakness in the gloved hand, than players at other positions do. Microvascular
changes have been found in the hands of otherwise healthy professional
baseball players in all positions, with a higher prevalence in catchers,
before the development of clinically important ischemia. Repetitive trauma
resulting from the impact of the baseball also leads to digital hypertrophy in
the index finger of the gloved hand of catchers. Gloves currently used by
professional catchers do not adequately protect the hand from repetitive
Immature competitive climbers demonstrate adaptive changes in the fingers
due to increased stress; however, there is no increase in the prevalence of
osteoarthritis in these athletes.
Techniques and indications for arthroscopic rotator cuff repair continue to
evolve. Certainly, mini-open repair has supplanted traditional open repair,
with equivalent outcomes and less morbidity. Controversy still exists with
regard to the use of the mini-open technique as opposed to the
all-arthroscopic technique. Many investigators have reported varying degrees
of success or failure in association with both open and arthroscopic rotator
cuff repairs. The importance of a learning curve in arthroscopic cuff repair
has been advanced by some authors. Regardless of the method of repair,
securing the cuff back to the anatomic footprint is important for successful
With more surgeons interested in arthroscopic rotator cuff repair, newer
techniques and devices continue to evolve to facilitate the arthroscopic
treatment of rotator cuff disease. The end-splitting knot-tightener was shown
to provide the most secure arthroscopic knots, and there was no difference
between these knots and hand-tied knots. Some newer devices alleviate the need
for arthroscopic knot-tying altogether. A comparison between a transosseous
tunnel repair and various arthroscopic techniques demonstrated that the
arthroscopic, doubly loaded suture anchor provided more stable initial
fixation than the open transosseous repair
It is important to repair the rotator cuff to the anatomic footprint. The
transosseous tunnel technique created more contact and greater overall
pressure distribution over a defined footprint when compared with suture
contrast, Millett et al. proposed the mattress double-anchor repair of the
rotator cuff, which allows for dissipation of the stress of the repair, more
points of fixation, and compression of the repaired cuff into the
procedure allows for an all-arthroscopic repair, with less suture management,
and simulates a traditional transosseous repair. Also, there are conflicting
data on single as opposed to double-row rotator cuff repairs, and this issue
is not resolved at this time.
The use of polymerase chain reaction for the evaluation of the torn rotator
cuff margin and the surrounding bursa demonstrated that both the cuff and the
bursa had increased mRNA levels of type-I and III collagen and that the cuff
margin also showed increased aggrecan mRNA levels, suggesting that both the
margin of the torn rotator cuff and the bursa are actively remodeling and may
be contributing to the healing process following repair.
Recurrence or retearing of the rotator cuff continues to be reported
following both open and arthroscopic repair. The importance of this finding is
unclear. It seems that the loss of cuff integrity has little effect on
outcomes when compared with those in patients with an intact cuff. In fact,
patients with a retear still showed improvement in all clinical areas
assessed, including strength.
The use of orthobiologic devices continues to be heavily researched. Gorman
reported an immunologic reaction in 22% (seven) of thirty-two patients who had
undergone a rotator cuff repair in which the Restore patch had been used for
augmentation. Malcarney et al. reported an inflammatory response and breakdown
of the cuff repair in four (16%) of twenty-five patients who had been managed
with the Restore
Importantly, those studies documented that the reactions were not an
infectious process and that they subsided with time and local care.
Nonoperative care remains the first line of treatment for supraspinatus
tendinopathy. A recent report questioned the benefit of the addition of
betamethasone to the injection, citing no benefit compared with a Xylocaine
injection alone. A randomized, double-blinded, placebo-controlled trial
established the efficacy of topical glyceryl nitrate for the treatment of
supraspinatus tendinopathy. Paoloni et al. reported significantly reduced pain
with activity (p = 0.03), at night (p = 0.03), and at rest as well as
increased range of motion and strength as compared with the results of tendon
rehabilitation alone at twenty-four
Subacromial and intra-articular shoulder injections are commonly performed
in the office setting. Recently, the reliability of intra-articular injection
has been called into question. One study demonstrated that anterior placement
of a spinal needle into the glenohumeral joint was done correctly in only 26%
of patients40. This
finding was in contrast with those of a previous cadaveric study that showed
this to be the most accurate position from which to enter the glenohumeral
joint. Numerous reports have documented the difficulty of accurately and
reproducibly entering the glenohumeral joint. Some investigators have
recommended that the intra-articular injection be placed under fluoroscopic
guidance to ensure accurate delivery of the medication.
Impingement, rotator cuff tendinopathy, and the role of acromioplasty
remain controversial. Some have argued that simple débridement of the
inflamed bursa and cuff provides results that are equivalent or superior to
those of acromioplasty. A positive preoperative subacromial injection test has
been associated with a better postoperative result following subacromial
decompression. The extent of acromioplasty that is needed also remains unclear
at this time. Certainly, a reasonable goal of acromioplasty includes removing
spurs associated with the coracoacromial ligament and conversion to a type-1
acromion configuration. An anatomical study showed that removal of 4 mm of
bone from the undersurface of the anterior edge of the acromion resulted in
release of 56% of the anterior deltoid. A 5.5-mm resection released 77% of the
Our understanding of the mechanics and pathology of throwing continues to
evolve. Counseling young pitchers, parents, and coaches remains important.
Young throwing athletes demonstrate a decrease in elevation and total range of
motion of the dominant shoulder. This change is most pronounced between the
thirteenth and fourteenth years of age, the year before the peak prevalence of
Little Leaguer's shoulder. The decreased range of motion may cause increased
stress at the physis during throwing. Also, as more and more young girls are
playing sports competitively, gender-specific issues continue to arise. Youth
windmill softball pitching causes excessive distraction stress and joint
torque to the elbow and shoulder of the throwing arm. These forces are similar
to those found in baseball pitchers and college softball pitchers. A
recommendation has been made to consider limiting the number of pitches for
these windmill pitchers just as is done for baseball pitchers.
A good clinical evaluation is necessary for the accurate assessment of
patterns of shoulder instability. The evaluation of pitchers who have
instability remains difficult because of the abnormalities of the arc of
motion as well as side-to-side differences. This asymmetry is not present in
Arthroscopic repair can be a reliable procedure for the treatment of some
labral lesions in overhead athletes. However, the rate of return of baseball
players who have overuse injuries is lower than that of overhead athletes with
The surgical treatment of shoulder instability traditionally has been
performed as an open procedure. Recent literature has shown equivalent results
in terms of stability and has shown more favorable patient outcomes in
association with arthroscopic stabilization, even in high-demand and collision
The treatment of shoulder dislocations in young patients traditionally has
been nonoperative, with a high risk for recurrent dislocations based on age. A
randomized, prospective trial established arthroscopy and labral repair
(rather than nonoperative measures) as the appropriate treatment for
first-time shoulder dislocations in young, active patients, with a difference
between the groups with regard to the rate of
Good results also have been reported following the treatment of chronic
anterior instability with arthroscopic reduction and fixation of osseous
Bankart lesions with suture
Closure of the rotator cuff interval appears to be integral to the success
and durability of arthroscopic anterior stabilization surgery. Closure of the
rotator cuff interval is more effective than thermal capsulorrhaphy for
stabilizing multidirectional laxity in the glenohumeral joint without the
associated risks inherent with the thermal probe. The axillary nerve is always
at risk during instability surgery and is closest to the capsule between the 5
and 7 o'clock positions.
Despite the increased ability to treat shoulder abnormalities
arthroscopically, open procedures continue to be commonly performed. A
meta-analysis demonstrated that open repair is more successful in terms of the
rate of recurrent instability and the return to
Clearly, controversy exists with regard to the best way to treat shoulder
instability. When attempting to reduce the intracapsular volume, an open,
lateral capsular shift is more successful than arthroscopic plication is, and
open procedures are particularly appropriate for the treatment of
multidirectional instability that requires a larger capsular shift. The
absolute amount of volume reduction that is required in order to achieve
modified anterior capsular shift with a longitudinal incision of the capsule
medially and osseous fixation of the inferior flap to the glenoid and labrum
in the 1 to 3 o'clock position has been associated with efficacy and
durability for the treatment of atraumatic anterior-inferior shoulder
The jerk test is used to document posterior instability, and a painful test
is a hallmark for predicting failure following the nonoperative treatment of
posteroinferior instability. Shoulders with symptomatic posteroinferior
instability and a painful jerk test have posteroinferior labral
Scapulothoracic motion is complex. In a three-dimensional motion analysis
of the scapula, throwing athletes demonstrated increased upward rotation,
internal rotation, and scapular retraction during humeral elevation as
compared with the normal population. These adaptations allow clearance of the
rotator cuff under the acromion, which facilitates throwing without
subacromial impingement. Fatigue of the scapular stabilizers leads to a
decrease in rotator cuff strength and a subsequently decreased ability to
center the humeral head in the glenoid fossa. Kibler discussed the
contribution of the scapula to the dynamics of shoulder motion and strength.
An unstable scapular base contributes to weakness of the shoulder and often is
the source of apparent rotator cuff weakness. The scapular retraction test has
been shown to be a critical portion of the examination of the injured
shoulder, and scapular strengthening and stabilization should be emphasized in
the rehabilitation of the shoulder injury.
The biceps tendon plays a role in stabilizing the humeral head and is also
known to be a source of shoulder pain when injured or diseased. Proper
treatment of the diseased biceps tendon remains unclear. Tenodesis, tenotomy,
and débridement are all commonly performed in various clinical
settings. Arthroscopic biceps tenotomy has been a reliable and successful
procedure for decreasing shoulder pain in patients with refractory tendonitis.
The procedure appears to be most appropriate for the older and less active
population. More active and younger individuals certainly fare better with a
tenodesis procedure. Recently, a technique for arthroscopic biceps tenodesis
Throwers continue to have medial-side elbow problems, including medial
collateral ligament insufficiency, chronic valgus overload, posteromedial
impingement, and posteromedial osteophytes. The diagnosis of medial-side elbow
disorders is difficult in throwing athletes. Evaluation of asymptomatic elbows
in professional baseball players with use of magnetic resonance imaging
demonstrated that 87% of the elbows had medial collateral ligament
abnormalities and 81% had findings consistent with posteromedial impingement.
These baseline findings must be considered when magnetic resonance imaging is
used as a factor in treatment decisions. A cadaveric study established that
medial collateral ligament insufficiency altered the contact area and pressure
between the posteromedial aspect of the trochlea and the olecranon, helping to
explain the development of posteromedial osteophytes. The "moving valgus
stress test" has been described as a physical examination technique that
is highly sensitive and specific for diagnosing insufficiency of the medial
collateral ligament or other abnormalities associated with chronic valgus
overload of the
Chronic exertional compartment syndrome continues to be a diagnostic
dilemma. Invasive compartment-pressure monitoring is expensive and requires
specialized equipment and substantial time. The sensitivity of near-infrared
spectroscopy for the diagnosis of chronic exertional compartment syndrome has
been found to be clinically equivalent to that of invasive intracompartmental
Tibial stress fractures continue to be commonly seen and are best treated
with activity modification. Treatment of recalcitrant stress fractures with
intramedullary nailing has enabled patients to return to sports at an average
of four months. This is an option for the treatment of chronic tibial stress
fractures. In one case, a fracture occurred after corticotomy and
intramedullary nailing of a chronic tibial stress fracture. The fracture was
treated nonoperatively, and the patient was able to return to play at eight
weeks; however, the dreaded black line persisted.
Muscle trauma is the most common musculoskeletal injury at all levels of
participation. Healing with a fibrotic response is common in patients with
these injuries. The role of anti-inflammatory medications has been questioned
with regard to decreased muscle regeneration and functional outcome. We
continue to search for interventions that can facilitate the treatment of
these injuries and encourage tissue repair. In a mouse model, the injection of
suramin (an antifibrotic agent) into the site of a muscle injury decreased
scar-tissue formation. In addition, suramin-treated muscles also had greater
fast twitch and tetanic strength compared with controls. Research to identify
the proper method and timing of intervention in the treatment of muscle injury
Despite our attempts to decrease the risk of deep venous thrombosis, this
complication remains a substantial problem in the care of the orthopaedic
patient. The association with arthroplasty has been well defined, but other
common orthopaedic procedures, such as arthroscopy, have not been as well
studied. A meta-analysis of deep venous thrombosis after knee arthroscopy
demonstrated an overall rate of 9.9% and a proximal rate of 2.1% after knee
arthroscopy without thromboprophylaxis. Additional reports in the chest
literature have documented the prevalence of deep venous thrombosis after
arthroscopy and the association with some nearly ubiquitous risk factors. To
date, there are no formal recommendations for the prevention of deep venous
thrombosis in patients undergoing arthroscopy; however, it seems prudent to
treat certain high-risk patients with prophylaxis against deep venous
An analysis of injuries in ice-hockey players demonstrated that concussion
was the most common injury, followed by sprains of the medial collateral
ligament of the knee. Additionally, hockey players appear to be at risk for
syndes-motic injuries rather than ankle sprains.
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 medical journals were
reviewed to identify these articles, which all have high-quality study design.
In addition to articles published previously in this journal or cited already
in this Update, ten level-I articles were identified that were relevant to
sports medicine. A list of those titles is appended to this review after the
standard bibliography. We have provided a brief commentary about each of the
articles to help to guide your further reading, in an evidence-based fashion,
in this subspecialty area.
The annual meeting of the Arthroscopy Association of North America (AANA)
will be held from May 18 through 21, 2006, in Hollywood, Florida. The annual
meeting of The American Orthopaedic Society for Sports Medicine (AOSSM) will
be held from June 29 through July 2, 2006, in Hershey, Pennsylvania.
Sports Medicine continues to be the most popular fellowship in orthopaedic
surgery, with almost half of all graduating residents seeking fellowships
applying. Accreditation continues to be an important goal of all fellowships
because this will eventually be a requirement to sit for the subspecialty
certification examination. Unfortunately, the match, which is coordinated by
the National Residency Matching Program, has recently been abandoned by the
fellowship directors. Hopefully, a suitable substitute can be developed in
order to fairly allow fellows the opportunity to seek quality programs.
Subspecialty certification is a reality. The first examination, developed
by the American Board of Orthopaedic Surgery (ABOS), is expected to be
administered in the fall of 2007. A pretest that can be used for fellowship
preparation has been developed and is available through the American
Orthopaedic Society for Sports Medicine (AOSSM). Additionally, the AOSSM is
working with the American Academy of Orthopaedic Surgeons to develop a sports
medicine review course that is tentatively planned for the summer of 2007.
Please contact the AOSSM at 847-292-4900 for more information on this
examination. The AOSSM is also involved in two new research endeavors; one is
a three-year articular cartilage research initiative, and the other is a
multicenter study on revision anterior cruciate ligament reconstruction. For
more information on these projects please see the AOSSM web site at
Rompe JD, Decking J, Schoellner C, Theis
C. Repetitive low-energy shock wave treatment for chronic lateral
epicondylitis in tennis players.
Am J Sports Med.
Seventy-eight patients with recalcitrant lateral epicondylitis were
enrolled in a randomized, placebo-controlled trial evaluating the effect of
low-energy extracorporeal shock wave treatment given weekly for three weeks
(treatment group; Group 1) or an identical placebo treatment (sham group;
Group 2). At three and twelve months, there was significantly (p = 0.001) more
improvement in terms of pain in Group 1 as compared with Group 2, although
both groups demonstrated improvement over the course of the study.
Extracorporeal shock wave therapy should be considered for the treatment of
recalcitrant lateral epicondylitis.
Witvrouw E, Danneels L, Van Tiggelen D, Willems
TM, Cambier D. Open versus closed kinetic chain exercises in
patellofemoral pain: a 5-year prospective randomized study.
This prospective, randomized trial investigated the long-term (five-year)
effects of open kinetic chain and closed kinetic chain exercises in the
treatment of patellofemoral pain syndrome. The results of both regimens were
generally favorable in terms of strength, function, and subjective complaints,
although only 20% of the patients reported being pain-free at five years. The
open kinetic chain group had less pain on the visual analog scale at night,
less swelling of the joint, and less pain descending stairs as compared with
the closed kinetic chain group. Open kinetic chain exercises do not need to be
avoided in the treatment of patellofemoral pain syndrome and should augment
traditional closed kinetic chain exercises.
Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M,
Ito Y. Reconstruction of the anterior cruciate ligament.
Single-versus double-bundle multistranded hamstring tendons.
Joint Surg Br.
This randomized, prospective study of 108 patients compared single and
double-bundle multistranded anterior cruciate ligament reconstructions. The
study demonstrated no difference between the groups in terms of anterior
laxity at either 20° or 70° of flexion or in terms of proprioception.
There was a decreased need for notchplasty in the double-bundle reconstruction
group. The authors found no advantage with the double-bundle anterior cruciate
Harilainen A, Sandelin J, Jansson
KA. Cross-pin femoral fixation versus metal interference screw
fixation in anterior cruciate ligament reconstruction with hamstring tendons:
results of a controlled prospective randomized study with 2-year follow-up.
This randomized trial compared cross-pin fixation (TransFix cross pin;
Arthrex, Naples, Florida) with metal interference screw fixation in patients
undergoing reconstruction of the anterior cruciate ligament with use of
hamstring tendons. The postoperative examiners and the patients were blinded
with regard to the fixation method. After two years of follow-up, there were
no significant or clinically relevant differences between the two methods of
fixation of the graft in the femoral tunnel.
Hill PF, Russell VJ, Salmon LJ, Pinczewski
LA. The influence of supplementary tibial fixation on laxity
measurements after anterior cruciate ligament reconstruction with hamstring
tendons in female patients.
Am J Sports Med.
This prospective study of tibial fixation in female patients undergoing
anterior cruciate ligament reconstruction with use of hamstring tendons showed
that double fixation of the tibial graft with an interference screw and staple
reinforcement effectively reduced anterior laxity at two years postoperatively
as assessed with both the Lachman test and KT-1000 testing. This double tibial
fixation addresses the concern of laxity that has been seen in female patients
after tibial interference screw fixation, which is thought to be associated
with the decreased bone density in such patients. The improvement in fixation
strength and laxity measurements comes at a cost of increased anterior knee
pain with kneeling due to the staple fixation.
Spindler KP, Kuhn JE, Freedman KB, Matthews CE,
Dittus RS, Harrell FE Jr. Anterior cruciate ligament
reconstruction autograft choice: bone-tendon-bone versus hamstring: does it
really matter? A systematic review.
Am J Sports Med.
This was a review of nine randomized, controlled trials comparing anterior
cruciate ligament reconstructions performed with bone-patellar tendon-bone
autografts and hamstring autografts. The study evaluated the variables of
instrumented laxity and subjective data. The differences in the data were
often quite small and were not reproduced between the randomized, controlled
trials. A slight increase in anterior laxity was found in association with the
hamstring reconstructions, and anterior knee pain with kneeling was found more
frequently in the patellar tendon autograft group. Subjective differences
between the two reconstructions were not seen consistently. Overall, the
choice of graft type for anterior cruciate ligament reconstruction does not
appear to be the primary determinant of outcome. Rather, the status of the
meniscus and articular cartilage at the time of surgery has a more profound
influence on the outcome of anterior cruciate ligament reconstruction than the
graft type does.
Nicholas SJ, D'Amato MJ, Mullaney MJ, Tyler TF,
Kolstad K, McHugh MP. A prospectively randomized double-blind
study on the effect of initial graft tension on knee stability after anterior
cruciate ligament reconstruction.
Am J Sports Med.
This prospective, randomized, double-blind clinical trial of forty-nine
patients evaluated the effect of different graft tensions in bone-patellar
tendon-bone anterior cruciate ligament reconstructions. The grafts were
tensioned at either 45 or 90 N, and the range of motion and KT-1000
measurements were evaluated. Better arthrometric stability was obtained in the
high-tension group without overconstraint of the knee. Five of the patients in
the low-tension group had abnormal side-to-side laxity (as indicated by a
>5-mm difference in anterior tibial displacement). However, at an average
of twenty months postoperatively, no difference in functional outcome was
noted between the groups. Although the exact tension that is appropriate for
anterior cruciate ligament reconstruction remains unknown, it appears that 45
N of tension is not sufficient to restore normal knee stability.
McDevitt ER, Taylor DC, Miller MD, Gerber JP,
Ziemke G, Hinkin D, Uhorchak JM, Arciero RA, Pierre PS.
Functional bracing after anterior cruciate ligament reconstruction: a
prospective, randomized, multicenter study.
Am J Sports
This prospective, randomized, multicenter study evaluated functional
bracing after anterior cruciate ligament reconstruction. Patients with
chondral, meniscal, or multiple-ligament injuries were excluded. After two
years of follow-up, there was no difference between the groups with or without
bracing in terms of stability, functional testing, International Knee
Documentation Committee score, Lysholm score, range of motion, or isokinetic
strength-testing. Therefore, bracing generally is not recommended in the
setting of anterior cruciate ligament reconstruction.
Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols
CE, Fleming BC, Poole AR, Roos H. Rehabilitation after anterior
cruciate ligament reconstruction: a prospective, randomized, double-blind
comparison of programs administered over 2 different time intervals.
Am J Sports Med.
Accelerated and nonaccelerated rehabilitation protocols for anterior
cruciate ligament reconstruction were compared in a prospective, randomized,
double-blinded trial. All knees were reconstructed with an autologous
bone-patellar tendon-bone graft. Both protocols were associated with similar
outcomes in terms of clinical findings, patient satisfaction, function, and
biomarkers of cartilage metabolism. Regardless of the rehabilitation protocol,
two-year follow-up showed an increase in anterior laxity on KT-1000 testing as
compared with immediate postoperative values.
Nash CE, Mickan SM, Del Mar CB, Glasziou
PP. Resting injured limbs delays recovery: a systematic review.
J Fam Pract.
This review of the literature demonstrated that mobilization of an injured
but stable limb is associated with generally better results than
immobilization is. These improved results include earlier return to work or
sports activity, decreased pain and swelling, and increased range of motion.
The traditional belief that an injured limb benefits from immobilization
appears to be inaccurate, and, in fact, mobilization is associated with
generally better clinical results.
LaPrade RF, Tso A, Wentorf FA. Force
measurements on the fibular collateral ligament, popliteofibular ligament, and
popliteus tendon to applied loads. Am J Sports Med.
Bergfeld JA, Graham SM, Parker RD,
Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate
ligament reconstructions using single- and double-bundle tibial inlay
techniques. Am J Sports Med. 2005;
Shelbourne KD, Muthukaruppan Y.
Subjective results of nonoperatively treated, acute, isolated posterior
cruciate ligament injuries. Arthroscopy.
Pearsall AW 4th, Hollis JM. The effect
of posterior cruciate ligament injury and reconstruction on meniscal strain.
Am J Sports Med. 2004;32:
Sekiya JK, Haemmerle MJ, Stabile KJ,
Vogrin TM, Harner CD. Biomechanical analysis of a combined double-bundle
posterior cruciate ligament and posterolateral corner reconstruction.
Am J Sports Med. 2005;33:
Handy MH, Blessey PB, Kline AJ, Miller
MD. The graft/tunnel angles in posterior cruciate ligament reconstruction: a
cadaveric comparison of two techniques for femoral tunnel placement.
Kim SJ, Shin JW, Lee CH, Shin HJ, Kim
SH, Jeong JH, Lee JW. Biomechanical comparisons of three different tibial
tunnel directions in posterior cruciate ligament reconstruction.
Onate JA, Guskiewicz KM, Marshall SW,
Giuliani C, Yu B, Garrett WE. Instruction of jump-landing technique using
videotape feedback: altering lower extremity motion patterns. Am J
Sports Med. 2005;33:
Hewett TE, Myer GD, Ford KR, Heidt RS
Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P.
Biomechanical measures of neuromuscular control and valgus loading of the knee
predict anterior cruciate ligament injury risk in female athletes: a
prospective study. Am J Sports Med.
Agel J, Arendt E, Bershadsky B. Anterior
cruciate ligament injury in national collegiate athletic association
basketball and soccer: a 13-year review. Am J Sports Med.
Seneviratne A, Attia E, Williams RJ,
Rodeo SA, Hannafin JA. The effect of estrogen on ovine anterior cruciate
ligament fibroblasts: cell proliferation and collagen synthesis. Am J
Sports Med. 2004;32:
Lombardo S, Sethi PM, Starkey C.
Intercondylar notch stenosis is not a risk factor for anterior cruciate
ligament tears in professional male basketball players: an 11-year prospective
study. Am J Sports Med.
Yamamoto Y, Hsu WH, Woo S, Van Scyoc AH,
Takakura Y, Debski RE. Knee stability and graft function after anterior
cruciate ligament reconstruction: a comparison of a lateral and an anatomical
femoral tunnel placement. Am J Sports Med.
Dunn WR, Lyman S, Lincoln AE, Amoroso
PJ, Wickiewicz T, Marx RG. The effect of anterior cruciate ligament
reconstruction on the risk of knee reinjury. Am J Sports Med.
Nebelung W, Wuschech H. Thirty-five
years of follow-up of anterior cruciate ligament-deficient knees in high-level
O'Connor DP, Laughlin MS, Woods GW.
Factors related to additional knee injuries after anterior cruciate ligament
Lee GP, Diduch DR. Deteriorating
outcomes after meniscal repair using the Meniscus Arrow in knees undergoing
concurrent anterior cruciate ligament reconstruction: increased failure rate
with long-term follow-up. Am J Sports Med.
LaPrade RF, Wills NJ. Kissing cartilage
lesions of the knee caused by a bioabsorbable meniscal repair device: a case
report. Am J Sports Med.
Rijk PC, Tigchelaar-Gutter W, Bernoski
FP, Van Noorden CJ. Histologic changes in articular cartilage after medial
meniscus replacement in rabbits. Arthroscopy.
Kaplan LD, Schurhoff MR, Selesnick H,
Thorpe M, Uribe JW. Magnetic resonance imaging of the knee in asymptomatic
professional basketball players. Arthroscopy.
Larsen MW, Pietrzak WS, DeLee JC.
Fixation of osteochondritis dissecans lesions using poly(l-lactic
acid)/poly(glycolic acid) copolymer bioabsorbable screws. Am J Sports
Gill TJ, McCulloch PC, Glasson SS,
Blanchet T, Morris EA. Chondral defect repair after the microfracture
procedure: a nonhuman primate model. Am J Sports Med.
Cameron-Donaldson M, Holland C,
Hungerford DS, Frondoza CG. Cartilage debris increases the expression of
chondrodestructive tumor necrosis factor-alpha by articular chondrocytes.
Virchenko O, Skoglund B, Aspenberg P.
Parecoxib impairs early tendon repair but improves later remodeling. Am
J Sports Med. 2004;32:
Carney JR, Mologne TS, Muldoon M, Cox
JS. Long-term evaluation of the Roux-Elmslie-Trillat procedure for patellar
instability: a 26-year follow-up. Am J Sports Med.
Silver WP, Creighton RA,
Triantafillopoulos IK, Devkota AC, Weinhold PS, Karas SG. Thermal
microdebridement does not affect the time zero biomechanical properties of
human patellar tendons. Am J Sports Med. 2004;
Kelly BT, Shapiro GS, Digiovanni CW,
Buly RL, Potter HG, Hannafin JA. Vascularity of the hip labrum: a cadaveric
investigation. Arthroscopy. 2005;
Mardones RM, Gonzalez C, Chen Q, Zobitz
M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular
impingement: evaluation of the effect of the size of the resection. J
Bone Joint Surg Am. 2005;87:
Valderrabano V, Perren T, Ryf C,
Rillmann P, Hintermann B. Snowboarder's talus fracture: treatment outcome of
20 cases after 3.5 years. Am J Sports Med.
Torjussen J, Bahr R. Injuries among
competitive snowboarders at the national elite level. Am J Sports
Mologne TS, Lundeen JM, Clapper MF,
O'Brien TJ. Early screw fixation versus casting in the treatment of acute
Jones fractures. Am J Sports Med.
Reese K, Litsky A, Kaeding C, Pedroza A,
Shah N. Cannulated screw fixation of Jones fractures: a clinical and
biomechanical study. Am J Sports Med.
Porter DA, Duncan M, Meyer SJ. Fifth
metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel
screw in the competitive and recreational athlete: a clinical and radiographic
evaluation. Am J Sports Med. 2005;
Swartz EE, Norkus SA, Cappaert T,
Decoster LC. Football equipment design affects face mask removal efficiency.
Am J Sports Med. 2005;33:
Chhabra A, Goradia VK, Francke EI, Baer
GS, Monahan T, Kline AJ, Miller MD. In vitro analysis of rotator cuff repairs:
a comparison of arthroscopically inserted tacks or anchors with open
transosseous repairs. Arthroscopy.
Park MC, Cadet ER, Levine WN, Bigliani
LU, Ahmad CS. Tendon-to-bone pressure distributions at a repaired rotator cuff
footprint using transosseous suture and suture anchor fixation techniques.
Am J Sports Med. 2005; 33:
Millett PJ, Mazzocca A, Guanche CA.
Mattress double anchor footprint repair: a novel, arthroscopic rotator cuff
repair technique. Arthroscopy. 2004;
Malcarney HL, Bonar F, Murrell GA. Early
inflammatory reaction after rotator cuff repair with a porcine small intestine
submucosal implant: a report of 4 cases. Am J Sports Med.
Paoloni JA, Appleyard RC, Nelson J,
Murrell GA. Topical glyceryl trinitrate application in the treatment of
chronic supraspinatus tendinopathy: a randomized, double-blinded,
placebo-controlled clinical trial. Am J Sports Med.
Sethi PM, Kingston S, Elattrache N.
Accuracy of anterior intra-articular injection of the glenohumeral joint.
Ide J, Maeda S, Takagi K. Sports
activity after arthroscopic superior labral repair using suture anchors in
overhead-throwing athletes. Am J Sports Med.
Bottoni CR, Franks BR, Moore JH,
DeBerardino TM, Taylor DC, Arciero RA. Operative stabilization of posterior
shoulder instability. Am J Sports Med. 2005;
Mazzocca AD, Brown FM Jr, Carreira DS,
Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision
and contact athletes. Am J Sports Med.
Ide J, Maeda S, Takagi K. Arthroscopic
Bankart repair using suture anchors in athletes: patient selection and
postoperative sports activity. Am J Sports Med.
Kirkley A, Werstine R, Ratjek A, Griffin
S. Prospective randomized clinical trial comparing the effectiveness of
immediate arthroscopic stabilization versus immobilization and rehabilitation
in first traumatic anterior dislocations of the shoulder: long-term
Sugaya H, Moriishi J, Kanisawa I,
Tsuchiya A. Arthroscopic osseous Bankart repair for chronic recurrent
traumatic anterior glenohumeral instability. J Bone Joint Surg
Mohtadi NG, Bitar IJ, Sasyniuk TM,
Hollinshead RM, Harper WP. Arthroscopic versus open repair for traumatic
anterior shoulder instability: a meta-analysis. Arthroscopy.
Cohen SB, Wiley W, Goradia VK, Pearson
S, Miller MD. Anterior capsulorrhaphy: an in vitro comparison of volume
reduction—arthroscopic plication versus open capsular shift.
Marquardt B, Pötzl W, Witt KA,
Steinbeck J. A modified capsular shift for atraumatic anterior-inferior
shoulder instability. Am J Sports Med.
Kim SH, Park JC, Park JS, Oh I. Painful
jerk test: a predictor of success in nonoperative treatment of posteroinferior
instability of the shoulder. Am J Sports Med.
O'Driscoll SW, Lawton RL, Smith AM. The
"moving valgus stress test" for medial collateral ligament tears
of the elbow. Am J Sports Med. 2005;
van den Brand JG, Nelson T, Verleisdonk
EJ, van der Werken C. The diagnostic value of intracompartmental pressure
measurement, magnetic resonance imaging, and near-infrared spectroscopy in
chronic exertional compartment syndrome: a prospective study in 50 patients.
Am J Sports Med. 2005;33:
Ilahi OA, Reddy J, Ahmad I. Deep venous
thrombosis after knee arthroscopy: a meta-analysis.